Question & AnswerQ&A (PHILHEALTH CIRCULAR NO. 014, S. 2014)
The circular aims to revise guidelines for the PhilHealth outpatient Anti-Tuberculosis Directly Observed Treatment Short-Course (DOTS) benefit package to expand coverage to other first-line drug sensitive TB cases, align with national TB control policies, and strengthen financial mechanisms for better provider performance.
PhilHealth members with TB cases susceptible to first-line anti-TB drugs, including new and retreatment cases (relapse, treatment after failure, return after default, previous treatment outcome unknown), whether bacteriologically confirmed or clinically diagnosed, pulmonary or extra-pulmonary, are eligible.
No, drug-resistant TB cases are excluded from the PhilHealth TB DOTS benefit package.
The fixed case rate is Php 4,000.00, paid in two installments: Php 2,500.00 after the intensive phase and Php 1,500.00 after the continuation (maintenance) phase.
Providers must comply with PhilHealth Circular 54 s-2012 policies, submit required documents including Performance Commitment, pay the accreditation fee, and ensure that TB DOTS physicians are accredited with PhilHealth.
Claims must include the PhilHealth Benefit Eligibility Form (PBEF) or other proof of eligibility, PhilHealth Claim Forms 1 and 2, and a copy of the patient's completed NTP treatment card.
The 'No Balance Billing' policy prohibits charging additional fees to indigent patients, ensuring that PhilHealth reimbursements cover all necessary expenses.
Reimbursement must be maintained in a trust fund and allocated as follows: 40% for facility fees, 25% for referring physicians, and 35% for the services of TB DOTS facility staff.
Claims will be paid for cases with outcomes of cured, treatment completed, died, or treatment failed.
Yes, such patients may avail of both the TB DOTS package and the Out-patient HIV/AIDS Treatment (OHAT) package in accredited facilities, but claims must be filed separately.